Evolution and use of a note classification scheme in an
electronic medical record

Author(s)

Thomas H. Payne, MD, Robert Kalus, MD, Jacquie Zehner, RHIT

Source

AMIA 2005 Symposium Proceedings, Pages 599-603

Publisher

Omnipress

Publication Date

Nov. 2005

Abstract

Titles of clinical notes within an electronic medical
record (EMR) are important because they influence
the speed and completeness of the review of a
patientís health record. We created a note
classification scheme our EMR consisting of a 2 level
hierarchy of note titles used to identify newly created
and existing text and scanned notes. In a sample of 3
of the 18 months since beginning production use, an
average of 2,810 notes are added each day. The
number of distinct note titles rose by 32 percent
between November 2003 and February 2005. Few
changes were made to the upper level of the
hierarchy. Thirty-three note titles accounted for 75%
of the notes entered in February 2005. Note titles
are one of several attributes that in conjunction with
the user interface used to display them may affect the
efficiency and completeness with which clinicians
review their patientís records.